Andrea J. Apter, MD, MA, MSc is a practicing physician and Professor of Medicine at the University of Pennsylvania. Her specialty is treating patients diagnosed with asthma. Before she was a doctor, Apter was a math teacher who worked with students from 6th grade on.

Both as a doctor and as a teacher, Apter knows the challenges of communicating numeric concepts in health education. To help, she along with collaborators, have proposed a model to make this task easier for all.

In this podcast, Dr. Apter talks with Helen Osborne about:

Why numeracy matters in healthcare and preventive medicine.

Strategies to improve understanding that givers and receivers of health information can use today.

In these podcasts, you get to listen in on my conversations with some pretty amazing people. You will hear what health literacy is, why it matters, and ways we all can help improve health understanding.

Today, I’m talking with Dr. Andrea Apter. She’s a practicing physician and professor of medicine at the University of Pennsylvania, specializing in the treatment of patients with asthma.

Before being a doctor, Dr. Apter was a math teacher, working with students from sixth grade on. Both as a doctor and a teacher, Dr. Apter knows the challenges of communicating numeric concepts in health education. Along with some collaborators, she’s proposed a model to make this task easier for all.

Welcome, Dr. Apter.

Dr. Apter: Thank you for having me.

Helen: To be honest, I’m really intrigued by the topic of health numeracy. I think my intrigue is the opposite end of yours. My intrigue is the fact that numbers have always been hard for me. From your perspective, why does health numeracy matter?

Dr. Apter: That’s been the subject of my research. The first thing that happened was that I noticed patients had trouble with numbers. It caught my attention because I used to be a math teacher.

I noticed that if a patient was asked to take 30mg of Prednisone and was given 5mg pills, it was very difficult for many patients to figure out how many pills they had to take. I noticed that many patients from all walks of life had trouble understanding milligrams and denominations of medications, even though most of these patients could make change very easily.

I also noticed that physicians were stumped by numerical concepts every once in a while. Then I began to read, and I found that there had been studies that showed that people from all walks of life, whether they were doctors or patients, had trouble with numbers. I wondered if it impacted on health communication.

Helen: Do you think you were more sensitive to it with your background as a math teacher?

Dr. Apter: I’m sure I was.

Helen: For the person who had a hard time with the Prednisone because the Prednisone pill wasn’t in the same amount that person needed to take, what was the implication in healthcare?

Dr. Apter: The implication was that the patient possibly didn’t understand the instructions, or said another way, that the physician gave the instructions in such a way that they were not understandable.

This was an opening for errors, perhaps preventing the patient from getting better or even causing an adverse event. Most of these mistakes probably wouldn’t lead to very serious end points individually, but they could all add up to not getting the best healthcare possible.

Helen: It sounds like in that situation the person needed to divide or multiply, one of the basic arithmetic concepts. Is that what people need to do the most in healthcare, to add, subtract, multiply or divide? Is there something more we’re asking of our patients?

Dr. Apter: There is a lot of attention paid to preventative medicine these days, which is risk, probability and fractions. Those are difficult for many people. That becomes very important.

There are even simpler mathematical concepts that may be difficult for some people, like simply reading numbers. As an asthma specialist, we sometimes give patients peak flow meters. They may be hard for people to read. In addition, we sometimes ask them to track their readings and put them on a line chart. That may be hard for patients.

I’m not trying to say that people are incompetent. These sorts of problems have been shown in other research to have nothing to do with basic intelligence.

Helen: I think I’m Exhibit A in that one.

I actually have the nerve to sometimes give presentations on numeracy, which I think is silly in ways but also good in ways. I introduce myself and say, “My daughter is a biologist, my son is an engineer, my husband is a physicist, and me, I don’t do numbers.” I’m almost proud of it that way.

Then I might say, “Why am I talking about it? Because I’m Exhibit A. I know what it’s like to not understand numbers.” I relate to that, and I appreciate your sensitivity. It doesn’t matter how strong we are in other areas. There seems to be a fine set of skills that makes numbers a little bit different.

Dr. Apter: I don’t know what it is, and I’m not immune to mistakes, either. We often get white counts given one way, and we have to convert them another way. I catch myself making a mistake every once in a while. I have a patient who is on a medication that I have to convert from one form to another all the time. I have to do it very carefully.

The point is that when patients are in front of doctors, they’re usually very anxious. It’s not a pleasant situation. Society can also make understanding of almost anything difficult.

Helen: It sounds like it’s certainly an issue in healthcare, which is what you do when someone comes to you needing medication or treatment, but you were saying that it’s also an issue in prevention and wellness. How do numbers crop up there?

Dr. Apter: If a doctor says to a patient, “If you lose 5% of your weight, your blood pressure will be much better, and your risk of stroke will be reduced,” in that sentence there are several mathematical concepts.

The doctor said 5% instead of saying how many pounds, which might be a simpler concept. Then the doctor said, “Your risk of dying from a stroke might be reduced.” Risk is a probability.

Helen: It’s not even just the numbers themselves. It’s the broader concepts. When I look at nutrition information, and I do look at this a fair amount because we’re talking about weight and measurement over the course of a day, and over the course of a week, there seem to be a lot of mathematical concepts in there that don’t look like numbers. They’re just words. It’s a plain old sentence like, “Reduce your weight.” It seems like there’s much more underneath all of that.

Dr. Apter: When you say things like, “If you take this medication, you will have a 1 in 10 chance of having _____ benefit, but if you stop smoking, your risk will be reduced much further to 1 in 100,” those are very difficult concepts.

Helen: I certainly appreciate the enormity of the challenge. What do you suggest we do about this?

Dr. Apter: I have suggestions for the people who deliver the information, which would be healthcare providers, and then I have some suggestions for those on the receiving end.

The message for those on the receiving end is to have courage and not fear telling people that you don’t understand, you would like another explanation, you’d like them to repeat it, or anything like that.

There are a lot of things practitioners can do. The onus is probably on them.

Helen: What are some of them?

Dr. Apter: The first thing is to simplify the numerical concept being used. You mentioned in the introduction that we put together a model of how that might be done.

We lined up on a grid all the mathematical concepts that are commonly used in talking to patients. We made a hierarchy from least difficult to most difficult using some concepts used by other researchers. We picked out the ones that would be most relevant in healthcare in our practice.

Helen: I’m actually looking at that paper as we speak. For the listeners of this podcast, we will have a link on the website. The article I’m looking at is called Numeracy and Communication with Patients: They Are Counting on Us. You are the first of several authors. This was published in the Journal ofGeneral Internal Medicine in 2008.

We will have a link for that. It’s a very important paper. It’s one I refer to a lot.

Dr. Apter: Thank you. The most difficult are at the bottom. The horizontal grid from left to right has the communication skills necessary for understanding information, going from simplest to hardest, from “describe” to “interpret” to “decision-making.”

Helen: What are some of those numeracy elements as they go from the easiest to the hardest? What are the types of tasks you’re including?

Dr. Apter: The easiest might be reading numbers, counting and telling time. The more difficult ones would be arithmetic operations, estimating size or trends, understanding percentages, problem solving, logic, reading tables, estimation of error, and uncertainty and risk. Those are examples. It’s not a perfect hierarchy. There is probably overlap.

Then going horizontally is information that is purely descriptive versus information that has to be interpreted versus information upon which a decision has to be made.

Helen: Can you tell me more what you mean by “describe”? I’m looking at this table under “frequency.” That’s the task, looking at frequency. What are you looking for a patient to do when you’re talking about “describe”?

Dr. Apter: Suppose a patient is told to lose 5% of their weight. That would place them in the chart under “understanding percentages,” sort of midway down the grid, forcing them to interpret what 5% of their weight means in terms of losing weight.

Instead, if the provider says, “Lose 15 pounds,” that moves up on the chart to just “reading numbers and description.” The patient doesn’t have to interpret.

The numerical concepts and communication are simplified by changing the way the information is given by moving upward on the grid toward an easier math concept and more toward the left from “interpret” to “describe.”

Helen: Thank you. I think this table is rather brilliant, and I hope everybody will get that article and look at it as we are talking about it. What else can health communicators do to make this easier?

Dr. Apter: Changing to a simpler concept is certainly one thing. One doesn’t have to go through all the machinations in that table. There are some other things, too. One is to format for clarity. One might want to give several formats. A provider might want to give both verbal and written instructions.

If it’s written, there should be a lot of attention to whitespace. Did your English teacher ever talk to you about whitespace?

Helen: I hope I was paying more attention in English class than I was in math class. Whitespace is the unprinted area of a page, correct?

Dr. Apter: Correct. It’s not cramming the whole page full of numbers, formatting carefully with paragraphs, and not having one gigantic 20-line paragraph that scares one away before one starts to read.

It’s combining words, tables, graphs and pictures, as simply as possible. There don’t have to be a lot of them. Maybe there could be one line or a few words and maybe a picture. It doesn’t have to have all of them.

That goes along with removing any non-essential information. For example, suppose there is a brochure of a hospital for a patient. What the patient might want to know is what facilities are there, like the X-ray department and laboratory. Extra information, such as how many beds there are and other superfluous information, might not be important and can be removed.

Helen: It sounds to me as if that’s really incorporating all those wonderful principles of plain language, but making sure to do it with numbers as well. I’m a very visual person, so those pictures help me a lot. That’s something I recommend doing, and I try to do it as well.

When you are writing about numbers, the old style guides always said to write out the number until 10 and then use the numeral. Do those rules still apply, or do you think we should have a little more latitude?

Dr. Apter: I’ve been trying to break the rules lately. I just use the numeral instead of writing it out because I think it’s clearer, even when it’s below 10, but I can’t promise the editors won’t change it. I see people doing it more and more.

Helen: I’ve been trying to do that more and more, too. If you’re saying that that’s the good thing to do, I think people can go forth and have a little more clout in their argument.

What about the role of symbols? I know you specialize in asthma. I happen to be working on materials lately about peak flow meter measurements. I’m taking the information this client is giving me, and they use the mathematic symbols for greater than and less than. What do you think about symbols like that, not just the numbers and words?

Dr. Apter: I think it depends on the audience and the reader. If I were to use it with a patient, I’d make sure that the patient knew it, that’s all. Doctors are very good at using lots of abbreviations and symbols. We have so many of them that we begin to think everybody knows what we’re talking about, and that’s not the case. One has to be careful about symbols, too.

Helen: I have this image of you right now as this kind of hybrid between a doctor and a math teacher. I keep thinking how reassuring it would be if I was your patient and you were explaining to me what the symbols were or how to do the calculations.

Dr. Apter: I’m as guilty as anybody of all these mistakes.

Helen: Do you find when you do this over and over again, as probably many of our listeners do, that you get caught up in assuming that everybody can use numbers as well as you can?

Dr. Apter: I think it’s easy to assume that somebody else is thinking the way that you are. That’s always problematic because we all come from different experiences.

Helen: That gets to the core of what health communication is all about. Beyond these strategies that people can use on a day-to-day basis, do you see greater ways to make a longer lasting difference in how people can understand and use numbers?

Dr. Apter: I think that’s a very difficult question. That’s the subject of my research. I assume that the answer is yes, of course, but there are a lot of difficulties. One is in measuring literacy.

In order to show an improvement, you have to measure whether the literacy changes. The literacy may depend on a particular medical situation, and there aren’t a lot of tools, questionnaires or ways of measuring literacy, so there isn’t a lot for specific situations.

Here I get into mathematical concepts. All tools or questionnaires have error in them. Whether the error is significant or not in these tools hasn’t been widely assessed. It’s really a beginning field.

Then one has to measure not only literacy, but how health improves. How to measure whether health improves is also very difficult. It often requires following patients over time, which is very difficult for patients and expensive for research.

Helen: You’re advocating that we go down that path of doing that good research.

Dr. Apter: Of course.

The other thing with literacy is that literacy rests on the educational experiences people have over the course of their lives. If people don’t get the very best education when they’re young, that influences literacy for the rest of their lives, and it influences the jobs, health insurance and healthcare that can be obtained. That has to be looked at, too. All of this is really a large task.

Helen: You’ve given us lots of strategies in the short term, some bigger ideas for research and some gigantic issues to tackle of changing the US educational system.. What are your recommendations for one thing we should add to our practice and one thing we should subtract from our practice?

Dr. Apter: That sounds like a great idea, and I like the words “add” and “subtract.”

Helen: What are your suggestions? What should we add, and what should we subtract on a day-to-day basis?

Dr. Apter: In terms of patient-provider interactions, I think these things have to be individualized. Any extra information that can be subtracted is really important.

Helen: You talked about adding and making it more individualized. You talked about subtracting, getting rid of all that extra stuff we don’t really always need to say or write about, and just confirming understanding for it all.

Thank you so very much for sharing this with me. As I said, this area fascinates me. I can’t think of a better person to interview than someone who not only is a doctor but also a math teacher. Thank you so much, Dr. Apter.

Dr. Apter: Thank you. It was really a pleasure.

Helen: I learned a lot from Dr. Apter and hope you did, too, but health literacy isn’t always easy. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, feel free to sign up for the free enewsletter, What’s New in Health Literacy Consulting.

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find more information about each episode, along with important links, at the Health Literacy Out Loud website, www.HealthLiteracyOutLoud.com.

Did you like this podcast? Did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.